Inspection on 24/05/07 for Red Thorn House

This inspection was carried out on 24th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Red Thorn House 27/09/05

Red Thorn House 19/04/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Red Thorn House Church Lane Terrington St John Wisbech Norfolk PE14 7SD Lead Inspector Andy Green Unannounced Inspection 24th May 2007 10.30a Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red Thorn House Address Church Lane Terrington St John Wisbech Norfolk PE14 7SD 01945 880877 01945 881438 redthornhouse@herewardcare.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hereward Care Services Ltd Miss Suzanne Mary Hollingworth Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Red Thorn House is a registered care home provided by Hereward Care Services Ltd. The home provides personal care and accommodation for eight adults who have a learning disability The home is situated in a rural area close to the centre of the village of Terrington St John which is near Wisbech. The home was opened in 2004 and is an extended detached house, built in the 1960’s. There are 5 single bedrooms on the ground floor, 3 with an en-suite facility. There is a shared bathroom for the remaining two rooms, a kitchen/dining area and reception. This area of the home is fully wheelchair accessible. There are 3 first floor bedrooms with en-suite facilities. There are a number of communal areas including a dining/quiet room, kitchen and two lounges. There are large, attractive gardens, which are secure, offering various areas for relaxation, space and activity as required by the residents. The fees range from £1076.25 to £1743.98 per week. Copies of CSCI inspection reports are made available to residents and their relatives upon request from the home’s office. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green, Regulation Inspector undertook this key unannounced inspection on 24th May 2007. He met with the operational manager, manager, members of care staff and residents to gather views regarding the services that are provided in the home. A number of records were inspected including care plans, training records, staff files, medication records, fire testing and health & safety records. A tour of the building and grounds was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information to prospective residents and their relatives before they move in to ensure that they are aware of all the services provided. EVIDENCE: There have been changes to the Statement of Purpose since the last inspection and the manager stated that the document is reviewed throughout the year to ensure that all required information remains up to date. There have been two admissions since the last inspection. There was evidence that prospective residents’ needs and aspirations are appropriately assessed. A home has a pre-admission assessment in place to ensure that the home obtains all relevant information including health, mobility and social care needs. Visits to the home prior to admission are arranged including carers, relatives, advocates and any other significant person in the resident’s life before a decision is made regarding admission to the home. The assessment process is detailed and gives information regarding communication, and appropriate risk assessments. It is clear that the resident and their family/representatives are fully involved in the assessment process including purchasing items for their rooms before moving in. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 8 Residents are accepted for an initial assessment period of three months to give the individual time to settle and assess whether the home can meet their needs. A review meeting takes place to monitor whether home can continue to meet the assessed needs of the resident. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with dignity and respect and receive personal care to meet their assessed needs. EVIDENCE: Two care plans were seen both of which contained comprehensive information in a person centred format. Pictorial aids are in place in the form of symbols and photographs to aid the resident’s participation and understanding as much as possible. The care plans are reviewed on a monthly basis with the resident and their carers where possible. Staff spoken to during the inspection confirmed that they fully participated in the care planning process to monitor and record any changes in care or preferences of the resident. There was evidence that the residents were actively involved in this process. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 10 All records are kept in a clear and accessible format and the key guidelines are laminated in the individual resident’s care file. It was noted, however, that a few of the documents were not signed and dated. The manager stated that she would action this immediately and inform all staff to ensure that there is a consistent approach regarding documentation. There is a good risk assessment process and together with the care plans are reviewed on a monthly basis and explained to the resident where necessary, and to the resident’s carer/advocate, if appropriate. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff provide appropriate support to ensure that residents can access the community to engage in activities appropriate to their needs. Residents have a choice of meals to meet their dietary needs and preferences. EVIDENCE: Residents are supported to take part in a wide range of activities suitable for their age and preferences or to continue activities in which they had been engaged in before admission to the home. There is an activities co-ordinator who consults with residents and staff to ensure that activities are arranged to meet individual need. During the inspection there was clear evidence of residents and staff engaging socially in the home and two residents and two staff were actively involved in a hectic football match in the garden A number of residents attend day services in the nearby towns of March and Kings Lynn. In addition, residents are encouraged to use local amenities such Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 12 as a nearby sports outdoor centre, library, having lunch out and going to the local pub. There are a variety of in-house activities including large floor/garden board games, arts and crafts sessions, cookery, table football and access to computer and e-mail. Regular shopping trips are arranged and the home has two vehicles available. Holidays and daytrips are arranged throughout the year including seaside resorts, picnics and places of interest. Residents rights to decision making are recognised and for one of the most One of the residents continues to go to church occasionally and the residents are encouraged to regularly have contact with their families and friends both in the community and at home. The home clearly promotes individual choice and independence and staff were seen to respect privacy by knocking before entering a residents rooms and assisting residents in a relaxed and social manner. Communication is proactively and creatively addressed through a variety of methods, which includes pictorial aids, Makaton where appropriate to the individuals need. Three residents were met during the inspection and they indicated that they were content with the support and services that they were receiving. Residents are encouraged and supported to help clean their rooms where possible and a number of residents participate with household tasks. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear guidelines regarding the safe administration of medication. A risk assessment procedure is in place to protect residents from potential hazards in and outside of the home. EVIDENCE: Residents are all registered with a local GP surgery and hospital outpatient appointments are also arranged as required. Care plans evidenced that regular healthcare checks are in place including optician and dental appointments. A risk assessment procedure is in place to protect residents from potential harm both in the home and when accessing the community. The home continues to give high priority to the delivery of personal care support which meets the needs of individual The majority of staff have attended courses on Makaton to assist with communication for individual residents. Additional input is received from a Speech and Language Therapist. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 14 Comment cards received at CSCI from residents and relatives confirmed that they were very satisfied with the care and support provided at the home. One comment card did raise some concerns regarding aspects of support and the manager stated that this had been dealt with through meetings with the relatives involved. Medication records were accurately recorded and staff receive medication awareness and administration training. Homely remedies are also used appropriately. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints process to ensure that residents and their representatives are able to raise concerns. There are suitable arrangements for ensuring the protection of residents from neglect or harm. EVIDENCE: The complaints procedure is in place as evidenced in the last inspection report and the Deputy Manager said there had not been any complaints. The policies and procedures are in place for Adult Protection and staff receive on going training in this area. Both members of staff spoken to gave a good account of the issues involved and were aware of the home’s Whistle Blowing Policy. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment of the home provides residents with a safe, comfortable and clean place to live. EVIDENCE: The home is very well presented and maintained and benefits from having a full-time maintenance person who is able to carry out ongoing decorations and repairs as required. He also maintains the gardens to a high standard so that residents can enjoy outdoor games as well as providing space for barbecues in summer and an area in which residents can grow plants, if they wish. Residents are encouraged to furnish/equip their bedrooms so that they are able to enjoy spending time in their own rooms as well as using communal facilities. Three bedrooms were inspected and they were well presented with evidence of personal belongings and a clear choice of creative decoration to reflect their individual tastes and preferences. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 17 The lounges are well furnished and there are televisions, videos, DVDs and music playing facilities available to residents. A new carpet has been laid in the lounge and all bedrooms have been redecorated since the last inspection. Two new cookers and a washing machine have also been purchased since the last inspection. A new conservatory has been added which provides improved office space to store all appropriate documents and admin equipment. The rest of the conservatory provides additional communal space for residents. The manager stated that All areas seen were clean and hygienic. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment policy and processes ensure that residents are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the residents they support EVIDENCE: All staff are issued with contracts of employment and job descriptions. Three staffs files were seen and they contained appropriate recruitment information including two references, application form and evidence of a satisfactory CRB/POVA checks. Supervision is carried out on a 6/8 weekly basis and notes are kept in the files in sealed envelopes, The home is fully staffed at present. The manager stated that there is some use of bank staff who are all well known to the resident group . There were sufficient numbers of staff on duty to meet the needs of the residents which included; seven carers 7am-3pm, seven carers 3pm-6pm, five carers 6pm-10pm and 2 night staff 10pm-7am. The manger or deputy manager are available on each shift. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 19 Four members of staff were spoken to and it was evident that there is an effective and enthusiastic staff team approach. Staff confirmed that they had received a thorough recruitment, induction and 6-weekly supervision. There is an ongoing training programme and staff stated that they had received training including; moving and handling, fire safety, food hygiene, first aid, medication administration, POVA, challenging behaviour, person centred planning, NVQ at levels 2 and 3 and autism. All staff spoken to were clearly enthusiastic about working in the home and enjoyed assisting residents with a creative and holistic approach. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to the home. The home is well managed and the staff are well supported to ensure that residents receive good quality care. EVIDENCE: Since the last inspection the deputy manager has been appointed as manager of the home and she has submitted an application to become registered with CSCI. Staff confirmed that they found the management style in the home to be supportive and inclusive and they are encouraged to participate in the development of the service. The operational manager visits the home to provide additional management support. She was visiting on the day and actively participated in the inspection. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 21 Records of weekly fire alarm and emergency lights testing were seen and found to be accurate. Service contracts are also in place to ensure that equipment and services in the home are maintained regularly. The manager stated that the Director of the organisation is receptive to staff suggestions and that he has made a number of visits to the home throughout the year. The example given in the last report regarding the resiting of the office has been actioned. Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 4 27 X 28 29 30 4 4 3 3 X 3 X 4 LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 4 17 STAFFING Standard No Score 31 4 32 X 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000062819.V342025.R01.S.doc X Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Red Thorn House Score 4 3 3 X 3 X 3 X X 3 X Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Red Thorn House DS0000062819.V342025.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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